Pancreatic Cancer

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  • Also Known As:
  • Exocrine pancreatic cancer
  • Pancreatic exocrine tumors
  • Pancreatic endocrine tumors
  • Pancreatic neuroendocrine tumors
  • Islet cell tumors
  • Pancreatic adenocarcinoma
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What is pancreatic cancer?

Pancreatic cancer is the uncontrolled growth of abnormal cells in the pancreas. The cancerous cells form malignant tumors, which damage tissue, keep the pancreas from working the way it should, and may eventually spread (metastasize) to nearby or distant organs and tissues.

The pancreas is a narrow, flat gland about six inches long located deep in your abdominal cavity, behind the stomach and below the liver. It has head, body, and tail sections. Its head section connects to the first part of the small intestine (duodenum).

  • Inside the pancreas, small ducts (tubes) feed digestive enzymes and bicarbonate produced by the pancreas into the pancreatic duct. This large duct carries these down the length of the pancreas, from the tail to the head section, and into the duodenum.
  • The common bile duct also usually runs through the head section of the pancreas, carrying bile from the liver and gallbladder into the small intestine.
  • The bile duct and pancreatic duct usually join just before entering the duodenum and share a common opening into the small intestine.

The pancreas consists of two kinds of tissues that perform different functions:

  • The exocrine pancreas makes, stores, and releases powerful enzymes to digest fats, proteins, and carbohydrates in the small intestine. Some of the enzymes are produced and carried in an inactive form to the small intestine, where the enzymes are activated as needed. Exocrine tissues also make and release bicarbonate that neutralizes stomach acids and allows for the activation of pancreatic enzymes.
  • The endocrine pancreas produces hormones, including insulin and glucagon, and releases them into the blood. These hormones regulate sugar (glucose) transport into the body’s cells, where it is used for energy and to help maintain normal blood sugar levels.

Most pancreatic cancers (about 95%) begin in the cells that make up exocrine tissues. These cancers are hard to detect at an early stage because symptoms are usually subtle or absent and tumors cannot usually be seen or felt during a physical exam. By the time symptoms such as jaundice occur, the cancer has often spread throughout the pancreas and beyond.

Cancer can also begin in the pancreatic cells that make hormones, which are called neuroendocrine cells. Neuroendocrine tumors, also known as islet cell tumors, are more rare than exocrine tumors.

  • Most islet cell tumors are noncancerous (benign) and do not spread. Those that are cancerous (malignant) tend to grow and spread more slowly than exocrine tumors.
  • Islet cell tumors can be detected earlier than exocrine cancers because they can cause signs and symptoms if they produce excess pancreatic hormones, such as insulin or glucagon. Simple tests may be used to measure levels of these hormones in the blood to determine if they are elevated.

Exocrine tumors (e.g., pancreatic ductal adenocarcinoma) will be the focus of the rest of this article because they are more common than islet cell tumors.

Pancreatic cancer is the fourth leading cause of cancer death in men and women in the United States. According to the American Cancer Society, nearly 57,000 Americans are diagnosed with pancreatic cancer each year, and about 46,000 die from it. It is slightly more common in men than women.

 

About Pancreatic Cancer

Risk Factors

The main risk factor for pancreatic cancer is smoking. About 25% of pancreatic cancers are thought to be a direct result of cigarette smoking. Cigar smoking and using smokeless tobacco products also increases risk. Your risk for pancreatic cancer starts to drop once you stop smoking.

Other risk factors include:

  • Being overweight
  • Having chronic pancreatitis
  • Having diabetes (the risk is most often increased in people with type 2 diabetes)
  • Exposure to industrial chemicals, such as certain pesticides and petroleum products
  • Having a family history of pancreatitis or pancreatic cancer
  • Having certain inherited conditions, such as hereditary breast and ovarian cancer syndrome, or familial atypical multiple mole melanoma (FAMMM) syndrome

Signs and Symptoms

Early signs and symptoms of pancreatic cancer are often either absent or subtle. When present, they may include:

  • Jaundice (yellowing of the skin and whites of the eyes)
  • Itchy skin
  • Dark urine
  • Light-colored stools
  • Abdominal and/or back pain
  • Nausea
  • Loss of appetite
  • Unexplained weight loss
  • Extreme tiredness (fatigue)

Since these symptoms are seen in other conditions besides cancer, they may be ignored or missed in the early stages. By the time chronic pain, vomiting, malabsorption, and, in some rare instances, problems with blood sugar control develop and are recognized, the pancreatic cancer has usually spread to other tissues and organs.

Testing

Currently, there are no established laboratory tests for the early detection or diagnosis of pancreatic cancer. Research is ongoing to find a test that detects pancreatic cancer in the early stages, when it is most treatable. Although some experimental tests have shown promise, no screening or diagnostic test is available yet.

Diagnosis is usually made based on physical exam and medical history, imaging tests (see below), and a biopsy. Usually, a biopsy is the only way to make a certain diagnosis of pancreatic cancer. For this procedure, a healthcare practitioner removes one or more tissue samples and they are examined by a pathologist.

  • A biopsy of pancreatic tissue can be performed by inserting a long, hollow needle through the skin over the abdomen and into the pancreas.
  • If your healthcare practitioner is doing an examination of your pancreas and surrounding organs using an endoscope or laparoscope, biopsy samples can be obtained at that time.
  • Less commonly, a healthcare practitioner will perform a surgery to remove a suspected tumor and will have it examined under the microscope.

Some imaging tests that may be used to detect pancreatic cancer include:

  • Computed tomography (CT) scan: useful for detecting pancreatic masses and determining the extent of cancer spread
  • Endoscopic retrograde cholangiopancreatography (ERCP): an endoscope (a hollow tube) is guided through your mouth, down your throat and stomach to your small intestine. A smaller tube (catheter) is inserted through the endoscope to inject contrast dye into the pancreatic and bile ducts. Abdominal x-rays are taken to examine the pancreas, gallbladder, and the ducts that carry digestive enzymes from those organs to the small intestine. If abnormal growths are identified, a biopsy (removal of a small piece of tissue) can be performed during ERCP.
  • Magnetic resonance cholangiopancreatography (MRCP): a specific type of magnetic resonance imaging (MRI) that uses powerful magnets and radio waves to create images of the pancreas, pancreatic duct, and bile ducts. It is often used before or instead of ERCP to look for abnormalities in the pancreas because it is faster and non-invasive. It is also useful in distinguishing pancreatitis from pancreatic cancer.
  • Ultrasound: may be used to create and send images of your pancreas to a video monitor. An endoscopic ultra sound is an exam that involves a thin, flexible tube that is used to view inside the digestive tract and is more accurate than an abdominal ultrasound.

For more information on imaging studies, see RadiologyInfo.org.

Laboratory tests:

If you are diagnosed with pancreatic cancer, some blood tests may be done to predict prognosis and/or monitor treatment. These may include:

  • CA 19-9 (Cancer antigen 19-9)—a tumor marker that is currently measured to monitor how well pancreatic cancer treatment is working. It is not useful for detection or diagnosis by itself because non-cancerous conditions can cause elevated CA 19-9 levels.
  • CEA (Carcinoembryonic antigen)—while not specific to pancreatic cancer, elevated levels of this tumor marker can predict poor survival in people with the disease.

Some general laboratory tests may be done to evaluate your overall health:

Staging and Treatment

Treatment of pancreatic cancer is based on establishing what stage the cancer is in. This is done by determining how much of the pancreas is affected and whether the cancer has spread to nearby lymph nodes or distant organs. A tumor may be described using a formal staging/naming system or by categorizing the cancer into one of the following types:

  • Resectable—can be surgically removed because it is still located only within the pancreas
  • Borderline resectable—cancer may have just reached nearby blood vessels but might still be completely removed with surgery
  • Unresectable—locally advanced, spread into nearby organs
  • Metastatic—spread to distant organs

Pancreatic cancer is diagnosed when it is still resectable less than 20% of the time. The type of surgery chosen to treat the disease depends on where the tumor is located, its size, how far it has spread, and your overall health.

Surgical procedures used to treat pancreatic cancer include the Whipple procedure, distal pancreatectomy, and total pancreatectomy. For an explanation of these surgeries, see the National Comprehensive Cancer Network’s (NCCN) Patient Guidelines on Pancreatic Cancer.

Radiation and chemotherapy may also be used to treat pancreatic cancer. These treatments may be used before surgery to shrink tumors or after surgery to destroy cancer that might have spread but escaped detection. Chemotherapy agents may be used alone or in combination with other drugs. When tumors cannot be removed surgically, chemotherapy and/or radiation may be the only treatment options to consider. Pancreatic cancer does not respond well to current treatments.

Research into new treatment options known as “targeted therapies” (drugs that act upon a specific feature of cancer cells) is an active and ongoing field. Attempts to develop new drugs that have specific targets are meant to cause less harm to normal, healthy cells. Tyrosine kinase inhibitors (TKIs) are drugs that target proteins in cancer cells that helps them grow. TKIs are currently being given with chemotherapy to treat some people with advanced pancreatic cancer.

Another new treatment option, immunotherapy (the use of medicines to trigger the body’s natural defense system to attack cancer cells), is being studied in clinical trials to treat advanced pancreatic cancer, cancer that has come back (recurred) after treatment, and cancer that has spread to other parts of the body (metastasized).

For people with recurring or inoperable pancreatic cancer, palliative (comfort-oriented) care is the main focus of treatment. These individuals may want to consider enrolling in clinical trials that assess new treatments.

Learn more about clinical trials at the National Cancer Institute website.

Related Images

  • Location of the pancreas. Image credit: Don Bliss, National Cancer Institute
  • The pancreas and nearby organs and structures. Image credit: Don Bliss, National Cancer Institute

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